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Portal vein thrombosis

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Updated 2024 AGA guidelines for the management of portal vein thrombosis in patients with cirrhosis.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of portal vein thrombosis are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2024), the European Association for the Study of the Liver (EASL 2024,2023,2016), the American Society of Hematology (ASH 2023), the American Association for the Study of Liver Diseases (AASLD 2021), the American ...
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Screening and diagnosis

Indications for screening: as per AGA 2024 guidelines, do not obtain routine screening for PVT in asymptomatic patients with compensated cirrhosis.
D
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  • Diagnosis

Classification and risk stratification

Prognosis: as per AASLD 2021 guidelines, insufficient evidence whether PVT in patients with cirrhosis is merely a reflection of progressive portal hypertension or independently causative of increased mortality, outside of liver transplant candidates.
I
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Diagnostic investigations

Diagnostic imaging, ultrasound: as per ACG 2020 guidelines, obtain Doppler ultrasound as the initial noninvasive modality for diagnosis of PVT.
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  • Diagnostic imaging (CT/MRI)

  • Diagnostic imaging (documentation)

  • Evaluation for underlying causes (general principles)

  • Evaluation for underlying causes (thrombophilia)

  • Evaluation for underlying causes (myeloproliferative disorders)

  • Evaluation for underlying causes (HCC)

Diagnostic procedures

Endoscopic variceal screening: as per AGA 2024 guidelines, obtain endoscopic variceal screening in patients with cirrhosis and PVT if they are not already on nonselective β-blocker therapy for bleeding prophylaxis. Avoid delaying the initiation of anticoagulation for PVT, as this decreases the chance of portal vein recanalization.
E

Respiratory support

Evaluation of new thrombocytopenia: as per EASL 2016 guidelines, screen for heparin-induced thrombocytopenia in patients with a sudden unexplained platelet count fall ≥ 50% or to a value < 150×10⁹ cells/L, especially if UFH is initiated.
A

Medical management

General principles: as per AASLD 2021 guidelines, obtain immediate consultation with surgery, critical care, interventional radiology, and hematology in all patients with recent PVT and concern for intestinal ischemia. Initiate anticoagulation. Proceed to surgery in cases of intestinal infarction.
E
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  • Indications for anticoagulation (non-cirrhotic PVT)

  • Indications for anticoagulation (PVT in cirrhosis)

  • Choice of anticoagulation

  • Duration of anticoagulation (testing for thrombophilia)

  • Duration of anticoagulation (non-cirrhotic PVT)

  • Duration of anticoagulation (PVT in cirrhosis)

  • Thrombolytic therapy

  • Beta-blockers

Therapeutic procedures

Portal vein recanalization
As per AASLD 2021 guidelines:
Consider performing portal vein recanalization followed by TIPS in liver transplant candidates with chronic PVT hindering a physiological anastomosis between the graft and recipient portal vein. Make this decision as part of a multidisciplinary management process, including surgical and interventional radiology expertise.
E
Consider performing portal vein recanalization followed by TIPS in patients with chronic PVT and recurrent bleeding and/or refractory ascites not manageable medically or endoscopically.
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  • TIPS

  • Endoscopic variceal ligation

Specific circumstances

Pregnant patients: as per EASL 2023 guidelines, counsel female patients with vascular liver disease that the condition is associated with preterm birth and operative delivery.
B

Follow-up and surveillance

Follow-up imaging, nonrecanalized patients
As per AGA 2024 guidelines:
Consider obtaining observation with repeat imaging every 3 months until clot regression in patients with cirrhosis without intestinal ischemia and recent (≤ 6 months) thrombosis involving the intrahepatic portal vein branches or when there is < 50% occlusion of the main portal vein, splenic vein, or mesenteric veins.
E
Obtain cross-sectional imaging every 3 months in patients with cirrhosis on anticoagulation for PVT to assess response to treatment, and if the clot regresses, continue anticoagulation if until transplantation or at least until clot resolution in nontransplant patients.
E

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  • Follow-up imaging (recanalized patients)